Download Guideline for Trachelectomy - University Hospitals Birmingham NHS

Guideline for Trachelectomy
Version History
Version
1.0
1.1
Date
24.11.08
10.08.11
1.2
1.3
1.4
30.08.11
09.09.11
20.09.11
1.5
2.0
14.11.11
15.11.11
Summary of Change/Process
Approved by the Governance Committee Chair
Reviewed and updated by Kavita Singh and sent to Gynae
NSSG for reviewing
Reviewed and updated by Kavita Singh
Reviewed and updated by members of the Gynae NSSG
Reviewed and approved by Guidelines Sub Group on 20
September 2011
With comments from Kavita Singh
Reviewed and endorsed by Guidelines Sub Group
Date Approved by Network Governance
November 2011
Date for Review
November 2014
Changes between version 1 and version 2
This guideline has updated the changes in surgical techniques, indication and follow
up of patients undergoing trachelectomy for management of their early cervical
cancer at Pan Birmingham Gynae Cancer Centre (PBGCC).
ENDORSED BY THE GOVERNANCE COMMITTEE
S:\Cancer Network\Guidelines\Guidelines And Pathways By Speciality\Gynae\Current Approved Versions (Word &
PDF)\Guideline For Trachelectomy - Version 2.0.DocS:\Cancer Network\Guidelines\Guidelines and Pathways by
Speciality\Gynae\Current Approved Versions (Word & PDF)\Guideline for Trachelectomy - version 2.0.doc
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1.
Scope of the Guideline
This guideline has been developed to include the indications for, and follow up
of, patients undergoing trachelectomy for cervical cancer.
2.
Background to Trachelectomy
2.1
This is fertility preserving surgery aimed at preserving the uterus in women
who are desirous of future pregnancy. There are different types of
trachelectomy and different surgical approaches to this procedure.
2.2
Trachelectomy can be a simple or radical trachelectomy. Simple
trachelectomy involves a supravaginal amputation of cervix. Radical
trachelectomy involves removal of cervix with the parametrium and vaginal
cuff. Trachelectomy can be accompanied with a cervical cerclage to prevent
cervical incompetence.
2.3
Over 400 cases have been performed world wide and in these cases there
have been 171 pregnancies reported with 109 live births. In these cases
there was a slightly higher than average risk of miscarriage (29%) and
preterm delivery rate of 20%.
2.4
Within Pan Birmingham Cancer Network trachelectomy is carried out at the
Gynaecology Cancer Centre at Sandwell and West Birmingham Hospitals
NHS Trust.
Guideline Statements
3.
Indications
3.1
Simple trachelectomy
a)
b)
c)
persistent CIN/CGIN with flushed or short ectocervix as a result of
previous multiple loop treatments.
stage 1A1/1A2 cervical cancer where the knife cone biopsy is not
feasible because of flushed ectocervix.
superficial low volume stage 1B1 cervical cancer (depth <3mm and
transverse spread <10mm).
3.2
Radical trachelectomy is recommended for stage 1b1 cervical cancer.
4.
Inclusion criteria
a)
b)
c)
Premenopausal women desirous of future pregnancy.
No evidence of pelvic node metastases.
Cervical tumour at least 1 cm away from internal cervical os on MRI.
ENDORSED BY THE GOVERNANCE COMMITTEE
S:\Cancer Network\Guidelines\Guidelines And Pathways By Speciality\Gynae\Current Approved Versions (Word &
PDF)\Guideline For Trachelectomy - Version 2.0.DocS:\Cancer Network\Guidelines\Guidelines and Pathways by
Speciality\Gynae\Current Approved Versions (Word & PDF)\Guideline for Trachelectomy - version 2.0.doc
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5.
Exclusion criteria
a)
b)
c)
clear cell or serous carcinoma.
Neuroendocrine carcinoma.
squamous cell carcinoma and adenocarcinomas with deep stromal
invasion +LVSI.
6.
Route of surgery
6.1
Simple trachelectomy is performed through a vaginal approach.
6.2
Radical trachelectomy: Vaginal approach has been most commonly used for
this procedure. However abdominal and laparoscopic approaches are now
being gradually favoured in view of the radicality of excision of parametrium.
At PBGCC laparoscopic radical trachelectomy is an accepted surgical route.
Fertility outcome data after abdominal and laparoscopic radical trachelectomy
has not been published as an insufficient number of cases have been
performed worldwide via these routes.
6.3
Two stage treatment is preferred. Firstly laparoscopic pelvic
lymphadenectomy and secondly, only in absence of metastatic disease, a
trachelectomy is performed. Evidence suggests avoidance of
parametrectomy is safe for stage 1A2 and radical trachelectomy for 1B1
cervical cancer.
7.
Role of cervical cerclage with trachelectomy
Cervical cerclage is applied using ethilon sutures / Mersilene tape with knot
tied and buried at 6 o’clock position. Limitations of cerclage are cervical
stenosis, cryptomenorrhea and dysmenorrhea. Abandonment of elective
cerclage and instead recommending its insertion in second trimester of
pregnancy in selected cases is acceptable.
8.
Follow up after trachelectomy
8.1
All cases following trachelectomy should be followed up at the Cancer Centre.
All patients are encouraged to avoid pregnancy for the first 6 months to
ensure adequate healing, and no persistence or recurrence of disease.
8.2
There is no standardised protocol for follow up of patients after trachelectomy.
Follow up visits are aimed to:
a)
b)
c)
detect recurrence of disease.
treat any ongoing complications of procedure.
seek early guidance from obstetric colleagues if patient becomes
pregnant.
ENDORSED BY THE GOVERNANCE COMMITTEE
S:\Cancer Network\Guidelines\Guidelines And Pathways By Speciality\Gynae\Current Approved Versions (Word &
PDF)\Guideline For Trachelectomy - Version 2.0.DocS:\Cancer Network\Guidelines\Guidelines and Pathways by
Speciality\Gynae\Current Approved Versions (Word & PDF)\Guideline for Trachelectomy - version 2.0.doc
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9.
Interval and duration of follow up
All patients will be offered 6 monthly visits for the first 2 years.
10.
Modalities of Follow Up
These include:
a)
b)
c)
d)
e)
f)
clinical examination.
smear (isthmic and vaginal vault).
colposcopy.
cross sectional imaging.
HPV typing.
obstetric management.
10.1
Clinical Examination
This includes history, speculum and examinations of the vagina and rectum.
10.2
Smear
Endocervical brush and vault LBC will be performed twice in the first year
followed by yearly smears for ten years at the Cancer Centre. Endometrial
cells are disregarded as detected in >50% of these smears.
10.3
Colposcopy
Benefit of colposcopy is doubtful but examination on the colposcopy couch
makes easy visualisation and facilitates examination. Colposcopy is often
unsatisfactory because of the hidden transformation zone. Colposcopy and
biopsies are recommended only as a follow up of abnormal smears.
10.4
Imaging
MRI has been recommended at 6 and 12 months in other centres and until
there is more data available it is not a recommended practice unless it is for
investigation for any ongoing symptoms.
10.5
HPV typing
Its role is doubtful but in women with persistent smear abnormalities, HPV
typing may assist in selecting cases that may benefit from completion
hysterectomy after their childbearing.
10.6
Obstetric management
All patients should be registered with a nominated obstetrician managing high
risk pregnancies. The obstetrician is encouraged to communicate with the
gynaecologist. Antibiotic prophylaxis, prenatal steroid therapy and elective
caesarean are recommended.
ENDORSED BY THE GOVERNANCE COMMITTEE
S:\Cancer Network\Guidelines\Guidelines And Pathways By Speciality\Gynae\Current Approved Versions (Word &
PDF)\Guideline For Trachelectomy - Version 2.0.DocS:\Cancer Network\Guidelines\Guidelines and Pathways by
Speciality\Gynae\Current Approved Versions (Word & PDF)\Guideline for Trachelectomy - version 2.0.doc
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Monitoring of Guideline
Implementation of the guidance will be considered as a topic for audit by the NSSG
in 2013
Authors of Version 1
Kavita Singh
Janos Balega
Lara Barnish
Consultant Gynae Oncologist
Consultant Gynae Oncologist
Deputy Nurse Director
Author of Version 2
Kavita Singh
Consultant Gynae Oncologist
Approval Signatures
Pan Birmingham Cancer Network Governance Committee Chair
Name:
Doug Wulff
Signature:
Date: November 2011
Pan Birmingham Cancer Network Manager
Name:
Karen Metcalf
Signature:
Date: November 2011
Network Site Specific Group Clinical Chair
Name:
Signature:
Suhail Anwar
Date: November 2011
ENDORSED BY THE GOVERNANCE COMMITTEE
S:\Cancer Network\Guidelines\Guidelines And Pathways By Speciality\Gynae\Current Approved Versions (Word &
PDF)\Guideline For Trachelectomy - Version 2.0.DocS:\Cancer Network\Guidelines\Guidelines and Pathways by
Speciality\Gynae\Current Approved Versions (Word & PDF)\Guideline for Trachelectomy - version 2.0.doc
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